Basic Information
| Provider Information | |||||||||
| NPI: | 1447229026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOPISCHKE | ||||||||
| FirstName: | MARYNNE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6545 FRANCE AVE S | ||||||||
| Address2: | STE 210 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529282900 | ||||||||
| FaxNumber: | 9529282944 | ||||||||
| Practice Location | |||||||||
| Address1: | 6545 FRANCE AVE S | ||||||||
| Address2: | STE 210 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529282900 | ||||||||
| FaxNumber: | 9529282944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R113270-2 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 43841400 | 05 | WI | MEDICAID | 780824100 | 05 | MN | MEDICAID | 1007082 | 01 | MN | PREFERREDONE | OTHER | 4305471 | 05 | MT | MEDICAID | 851169 | 01 | MN | AMERICA'S PPO | OTHER | 8T414KO | 01 | MN | BLUECROSS BLUE SHIELD MN | OTHER | 0410560 | 01 | MN | MEDICA | OTHER | 151560 | 01 | MN | UCARE MN | OTHER | HP33242 | 01 | MN | HEALTHPARTNERS | OTHER |